Editorial supplement: Patient self-management support
Financial support for this editorial supplement was provided by the American Academy of Family Physicians Foundation.
Health coaching helps patients gain the knowledge, skills, tools, and confidence to become active participants in their own care. Health coaches help patients set their own health goals and then support their efforts to achieve those goals. The familiar adage “Give a man a fish, and he eats for a day. Teach a man to fish, and he eats for a lifetime,” demonstrates the difference between traditional approaches to care, which are often focused on saving the patient, and coaching.1 Every day, patients with chronic conditions must by themselves make important health decisions on things like diet, exercise and taking medications. Coaching teaches patients to fish.
Registered nurses, pharmacists, health educators, trained medical assistants, or even other patients, called peer coaches, often make the best health coaches because physicians frequently face severe time constraints. These coaches need training, as well as sufficient time to provide this essential service. They must work closely with the patient's physician or other health care provider to coordinate their efforts.
The content of health coaching
Some believe the coach's main job is to provide encouragement. Indeed, providing emotional support and motivation is an important part of coaching. But true health coaching does far more, offering concrete assistance to patients in five areas:
Ensuring understanding. Physicians are not always the best instructors. In an audiotaped study of 336 medical encounters, physicians estimated that they devoted an average of 8.9 minutes per visit to providing patients with information. But review of the tapes showed they actually devoted an average of only 1.3 minutes to this activity. As for the information itself, the study determined that 88 percent of the information was worded in technical language not easily understood by the patient.2 While physicians frequently attribute medication nonadherence to patient behavior, in fact, three out of four physicians in one study failed to give patients clear instructions on how to take their medications.3 In another study, 50 percent of patients, when asked to state how they were supposed to take a prescribed medication, did not understand the physician's instructions.4 When physicians asked patients to restate their instructions, the patients responded incorrectly 47 percent of the time.5 Given these findings, it is not surprising that 50 percent of patients leave an office visit not understanding what was said by the physician.6
A key function of health coaching is to make sure that patients understand the care plan. This function is carried out by “closing the loop,” also known as “teach back.” To close the loop, the coach asks the patient, for example, how he will take his medication the following day. If the patient's answer is incorrect, the coach corrects the patient and repeats the question until the patient can accurately repeat the instructions. In a study of patients with diabetes, those who underwent “closing the loop” had better A1C levels than those who didn't.5
Knowing your numbers. Most patients with diabetes do not know their A1C level or their A1C goal.7 In a randomized controlled trial, patients with diabetes who were taught their actual A1C level and their A1C goal improved their glycemic control more than a control group.7 A central function of health coaching is to teach patients their ABCs – A for A1C, B for blood pressure, C for cholesterol (specifically LDL cholesterol). Coaches also teach patients their ABC goals (for example, A1C of 7, blood pressure of 130/80, and LDL cholesterol of 100) and explain how to achieve those goals through healthy eating, physical activity, medication, and other actions.
Shared decision making. A participatory relationship between patient and physician is one of the most successful factors in promoting healthy behaviors.8,9 In a study of 752 ethnically diverse patients, information giving and collaborative decision making were associated with better adherence to medications, diet, and exercise.10
Patients who take control during their visits demonstrate improved control over their conditions. In one intervention study, patients encouraged to participate more actively in the clinical visit reduced their average A1C levels from 10.6 percent to 9.1 percent, while A1C levels for those who weren't encouraged increased from 10.3 percent to 10.6 percent.11 For patients with diabetes, significant associations exist among information giving, participatory decision making, healthier behaviors, and better outcomes.12,13,14
Because physicians and other clinicians often lack the time to engage in shared decision making, health coaches can provide this crucial medical care function. The foundation of successful health coaching lies in the concept of ask-tell-ask: Rather than telling patients information that they may already know or may not be interested in learning, good coaches ask patients what is important to them, what they want to learn, what choices they want to make, whether they agree with the clinician's instructions, and what behavior changes they are motivated to make. If there is one fundamental principle of health coaching, it is shared or collaborative decision making with patients. (See "Engaging Patients in Collaborative Care Plans" to learn more about this skill.)
Behavior change. It is a common misconception that information alone promotes healthy behavior change. Telling a patient that eating less fat will reduce LDL cholesterol and prevent heart attacks rarely has the desired result. While information is necessary, it is not sufficient. A systematic review of diabetes education trials found that in only 18 of 35 studies did patient education lead to an increase in patient knowledge and in only 13 of 32 studies did patient education lead to improved glycemic control (A1C).9 A disconnect between information and performance has been shown to also apply to blood pressure control and medication adherence.15,16
Driving behavior change requires setting realistic goals and creating an action plan in partnership with the patient. Action plans help informed and motivated patients target the behavior they would like to work on, such as healthy eating, physical activity, or medication adherence. These plans are a stark contrast with unrealistic instructions such as “lose 10 pounds, cut out all sugar, and walk 30 minutes each day.” In a recent randomized controlled trial, patients who set action plans reduced their A1C levels significantly more than those who received only education.17
Medication adherence. Only one-third of patients take their medication properly.18 Although adherence is a complicated, multifaceted issue, a participatory relationship between patient and physician with shared decision making appears to be the most important factor promoting proper behavior. The more actively the patient is involved, the higher the level of adherence.18,19 Health coaching focuses a great deal of energy on medication adherence because medications for diabetes, hypertension, and cholesterol are highly effective in helping patients reach their clinical goals.
UPCOMING ONLINE SEMINAR
On June 26 at 1 p.m. CDT, Amireh Ghorob, MPH, and Lauren Scherer, MS,will present a one-hour online seminar titled "Health Coaching: Practical Lessons From the Field." This free AAFP webinar is sponsored by the AAFP Foundation.
Here are some initial steps to take in implementing health coaching in your practice:
Learn how to train coaches and integrate them into patient care. See “Resources” below.
Pick a coaching model that works for your office. For instance, in the teamlet model (one clinician and one or two coaches), the medical assistant or other staff member on the teamlet does the coaching. In the modified teamlet model, the medical assistant or other staff member coaches multiple patient panels.
Create a workflow to integrate coaching into day-to-day operations.
Create standing orders to allow coaches to become a meaningful part of care delivery.
Ensure coaches have protected time to work with patients during or between clinic visits.
Provide health coach training to all staff members to ensure more consistent care.
Allow patients identified as needing a health coach to decide whether they want one.
Develop coaches through mentoring and monthly forums where you review coaching successes and challenges.